As I have mentioned before (see The Business of Editing: Culture and Editing), I get asked by clients to give an opinion on editing decisions made by other editors. (It would be much easier if they simply hired me to do the editing originally rather than asking my opinion after the fact, but that isn’t how it works these days!) I was recently asked to give an opinion on hyphenating right-heart syndrome (and its opposite, left-heart syndrome).

Medical terminology is a world of its own. Only in very recent editions, for example, did Dorland’s Illustrated Medical Dictionary, a standard reference in the United States, agree that disease and syndrome names should generally not be possessive. Dorland’s was slowly getting to that point, but until recently, it was a hodgepodge of possessive and nonpossessive. The result was that authors were resistant to dropping the possessive.

Similarly, in medical terminology, most journals refer to right heart syndrome, shunning the hyphen; a few are beginning to make the change. This raises an interesting problem for an editor: the hyphenated version is clear and accurate from both a reader’s perspective and grammatically; the nonhyphenated version is traditional and requires reader interpretation (does the author mean that his is the right [correct] heart syndrome or the syndrome that occurs on the right side of the heart?). From context one can often tell what is meant, but — and but is an important qualification — not always.

The question becomes one of 100%, all-the-time accuracy versus 98%, less-than-all-the-time accuracy: Which should an editor strive for? More importantly, which should an author strive for?

If we were discussing a novel, 98% — even 85% — accuracy can be acceptable. After all, by its very definition a novel is not intended to be true, accurate, real; it is intended to be, foremost, entertaining. In contrast, a work of nonfiction, such as a medical text or a history of the French Revolution or a biography of Lyndon Johnson, is intended to be factual, accurate, true, real. Consequently, not only does word choice matter, as discussed in The Business of Editing: Words Do Matter!, but so does how words are formed. Thus, the use of the hyphen in compounds is important.

There is no doubt that the rationale for omitting the hyphen in right heart syndrome is that it has been omitted since the naming of the disease. That may be good enough reasoning for an author, but should it be for an editor? There is yet another question: What weight should be given to author preference? In this regard, whether to use distension or distention doesn’t matter; both are acceptable spellings with the same meaning — essentially a schizoid word that can’t settle on one spelling. Yet they same deference to preference perhaps should not be extended to an author when deference can lead to less than 100% accuracy and understanding.

Consider it from another angle. What harm does hyphenating the phrase do to the fundamental goal of accurate communication? On the one hand, if hyphenating the phrase changes the intended meaning, then clearly it is harmful. On the other hand, if it clarifies meaning or enhances understanding or doesn’t change the intended meaning, then it isn’t harmful. If it isn’t harmful, why should it give way to an author preference that is based simply on “that is the way it has been done in the past”?

The reality of publishing today is that the editor is a weakened link in the process of taking a raw manuscript and making it into a polished, published product. In the early days of modern publishing, the editor had the time and was expected to make the effort to cajole an author into doing the correct thing, whether it took days, weeks, months, or even years. Quality of output was the key guiding factor. Today, the process is governed by tight schedules and cost saving. Today, the publisher backs the author and not the editor. The one common refrain I hear regularly these days (and for the past couple of decades) is to give the author what the author wants, regardless of whether it is correct or not.

If I were the editor of right heart syndrome, I would add the hyphen. It does no harm. Right-heart syndrome will not be misunderstood by the reader, unlike right heart syndrome, which can be misunderstood although not likely. There is no question in my mind that right-heart syndrome is accurate and clearly conveys to the reader that the discussion is about a syndrome of the right side of the heart.

My dilemma arises when I receive author feedback that says:

Ed: I have never seen a hyphen used for this syndrome at any time in the medical literature. I think most readers would find it odd. I suggest doing away with the hyphen throughout the text unless you can find documentation that this is correct.

What do I do? Even though I can find recent journal articles that support hyphenation, the truth is that the vast majority do not use the hyphen. Even though I can make the argument that adding the hyphen makes the term clearer, avoids any possibility of misunderstanding, and is grammatically correct, the current weight of published articles is against me. Even though I can say that hyphenating it conforms to American Medical Association (AMA) style guidelines, this appears to be irrelevant because, again, the weight of the literature is against me.

My response to the client is essentially to outline the dilemma discussed above. Because I was not the editor, I didn’t have to make the yes/no decision. Had I been the editor, I think I would have cited a couple of recent articles that do use hyphenation and outline why I think hyphenation is the better choice, and then I would kick the ball back to the client for the final decision. In the end, it depends on whether the client prefers to accede to the author’s wishes and avoid a fight.

Yet knowing that, after the fact, the client is likely to accede to the author’s wishes, does not relieve me of the responsibility of doing what I consider correct while editing. Consequently, I would hyphenate the phrase (absent initial instructions from the client to the contrary) and if questioned give my rationale. The point is that the editor is obligated to do the correct thing even if it is subsequently undone by the client. The editor’s job is to change potentially less-than-accurate terminology into precise, accurate terminology without sacrificing meaning; it is the client’s job to decide whether it is better to be fashionable or accurate.

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“If I were the editor of right heart syndrome, I would add the hyphen. It does no harm. Right-heart syndrome will not be misunderstood by the reader, unlike right heart syndrome, which can be misunderstood although not likely. There is no question in my mind that right-heart syndrome is accurate and clearly conveys to the reader that the discussion is about a syndrome of the right side of the heart.”

[…] know it hasn’t been very long since I last discussed the problem of hyphenation (see The Business of Editing: The Hyphenated Compound), yet it needs to be raised again. I recently had a discussion with a couple of younger editors […]